The Breast
KRISTOFF ARMAND E. TAN
HANNAH LOIS KANGLEON-TAN
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Part 1
Embryology and Anatomy
Physiology
Course Benign Breast Conditions
Outline Part 2
Breast Cancer
Screening and Staging
Diagnosis and Treatment
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RISK FACTORS
For Developing Breast Cancer
Genetics
Hormonal Non-Hormonal
• Sporadic 65-75%
• Increased estrogen exposure • Radiation
• Familial 20-30%
- Early menarche • Alcohol consumption
• Hereditary 5-10%
- Late menopause • High fat intake
- Nulliparity
- Obesity
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GAIL MODEL
Risk Assessment
Models
Average Risk = 12%
• Gail Model
• Claus Model
• BRCAPRO Model
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RISK MANAGEMENT
For High Risk Patients
Active Surveillance and
Screening Lifestyle Modification
About Me
Chemoprevention Risk Reducing Surgery
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BRCA1 vs BRCA2
COMPARISON
BRCA1 BRCA2
GERMLINE located on located on
MUTATIONS chromosome arm 17q chromosome arm 13q
Breast cancer risk: 85% Breast cancer risk: 85%
Ovarian cancer risk: 40% Ovarian cancer risk: 20%
Likely hormone negative Likely hormone negative
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DISTANT METASTASIS
PRIMARY BREAST CANCER
NATURAL
HISTORY
AXILLARY NODE METASTASIS
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DISTANT METASTASIS
PRIMARY BREAST CANCER
NATURAL
HISTORY
AXILLARY NODE METASTASIS
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DISTANT METASTASIS
PRIMARY BREAST CANCER
NATURAL
HISTORY
AXILLARY NODE METASTASIS
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Carcinoma In Situ
Cancer cells are in situ or invasive depending
on whether or not they invade through the
basement membrane.
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LOBULAR CARCINOMA IN SITU
• Originates from the terminal duct lobular units
• Develops only in the female breast
• Cytoplasmic mucoid globules are a distinctive
cellular feature
• Usually an incidental finding
• A marker of increased risk for invasive breast
cancer
• NOT an anatomic precursor
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DUCTAL CARCINOMA IN SITU
• Predominantly seen in female breast
- 5% in male breast
• papillary growths within the duct lumina
• Classified based on nuclear grade and
necrosis
• Risk for invasive cancer - fivefold
• Anatomic precursor of IDC
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INVASIVE BREAST CARCINOMA
1. Paget’s disease of the nipple
2. Invasive ductal carcinoma (AdenoCa), 80%
3. Medullary carcinoma, 4%
4. Mucinous (colloid) carcinoma, 2%
5. Papillary carcinoma, 2%
6. Tubular carcinoma, 2%
7. Invasive lobular carcinoma, 10%
8. Rare cancers (adenoid cystic, squamous, apocrine)
DIAGNOSIS OF BREAST CANCER Inspection
• Symmetry
Examination • Size
• Shape
• Skin and nipple changes
Palpation
• All quadrants up to boundaries
• Axillary lymph node assessment
DIAGNOSIS OF BREAST CANCER Mammography
• Supplements history and PE
Imaging • Radiation to low to cause cancer
• MLO view – greater volume
• CC view – better compression and medial aspect
DIAGNOSIS OF BREAST CANCER Mammography
• Supplements history and PE
Imaging • Radiation to low to cause cancer
• MLO view – greater volume
• CC view – better compression and medial aspect
Ultrasonography
• Determine echogenic qualities
• Lymph node assessment
• Used along with biopsy techniques
DIAGNOSIS OF BREAST CANCER Mammography
• Supplements history and PE
Imaging • Radiation to low to cause cancer
• MLO view – greater volume
• CC view – better compression and medial aspect
Ultrasonography
• Determine echogenic qualities
• Lymph node assessment
• Used along with biopsy techniques
Magnetic Resonance Imaging
• BRCA patients
• Unknown primary
• Assess neoadjuvant therapy and recurrence
DIAGNOSIS OF BREAST CANCER
Non-Palpable Lesions
Biopsy • Stereotactic techniques
Palpable Lesions
• Fine Needle Aspiration
• Core Needle Biopsy
• Open Biopsy (Excision or Incision)
An open and core needle biopsy specimen
can be checked for tumor biomarkers
TUMOR
BIOMARKERS
Hormone Receptors ER and PR
Growth Factor Receptors HER-2/neu
Indices of Apoptosis P53, Bcl-2
Indices of Proliferation Ki-67
Indices of Angiogenesis VEGF
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Clinical Staging
of Breast Cancer
Tumor Size
T1 T2 T3 T4
T <2 cm 2 – 5 cm >5 cm
skin or chest
wall involved
Lymph Nodes
NO N1 N2
N No lymph node
involvement
Solitary lymph
node
Matted lymph
nodes
Metastasis M0
Without M1
M distant
metastasis
With distant
metastasis
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Clinical Staging
of Breast Cancer
Easy way to remember staging
• Stage IV – M1
• Stage IIIB – T4
• Stage IIIA – N2
• Stage IIB – T + N = 3 Exception to the rule!
T3 N1 M0 = Stage IIIA
• Stage IIA – T + N = 2
• Stage I – T1
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Clinical Staging
of Breast Cancer
Easy way to remember staging
• Stage IV – M1
• Stage IIIb – T4 Locally advanced
(Inoperable)
• Stage IIIa – N2
• Stage IIb – T + N = 3
Early Invasive
• Stage IIa – T + N = 2 (Operable)
• Stage I – T1
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Clinical Staging
of Breast Cancer
Easy way to remember staging
• Stage IV – M1
• Stage IIIb – T4 Locally advanced
Neoadjuvant Surgery
(Inoperable)
• Stage IIIa – N2
• Stage IIb – T + N = 3
Early Invasive
Surgery Adjuvant
• Stage IIa – T + N = 2 (Operable)
• Stage I – T1
How is Breast Cancer
Treated?
• Treated by Stage
• Early Invasive – Surgery + adjuvant
• Locally advanced – Neoadjuvant +
surgery
• Local AND systemic treatment
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• Surgery for breast
Course of Mastectomy vs BCS
Treatment • Surgery for axilla
ALND vs SLNB
Locoregional • Radiotherapy
If with positive LN or margins
Or if BCS was done
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• Chemotherapy
Course of Almost all cases, OncotypeDX
Treatment • Hormonal Therapy (Tamoxifen/AI)
If ER or PR positive
Systemic • Anti Her2 Therapy (Trastuzumab)
If HER2 positive
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Other Considerations
Breast Cancer in Pregnancy
• 1 in every 3000 pregnant women
• No radiotherapy until delivery
• MRM at 1st and 2nd trimester
• BCS at 3rd trimester
• Risk of abortion and birth defects
from chemotherapy
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Other Considerations
Phyllodes Tumor
• Benign, Borderline or Malignant
• Difficult to diagnose with imaging and
FNA
• Excision with 1cm margins
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Other Considerations
Male Breast Cancer
• Benign, Borderline or Malignant
• Difficult to diagnose with imaging and
FNA
• Excision with 1cm margins
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RISK FACTORS AND ASSESSMENT
MODELS
THERAPEUTIC MANAGEMENT
Infographic
The Breast
Part 2
slide
DIAGNOSTIC MANAGEMENT
